Ophthalmic Artery Aneurysm Research Articles

Endovascular Treatment of Ruptured Intradural Ophthalmic Artery Aneurysm

We present a unique case of ruptured intradural ophthalmic artery aneurysm in a young man who presented with subarachnoid hemorrhage. By endovascular technique we successfully excluded the aneurysm from the circulation with preservation of antegrade flow in the ophthalmic artery. The presenting features and the technique of the treatment are described with a review of the literature.

Lateral Transcanthal-Microsurgical Resection of a Nontraumatic Intraorbital Ophthalmic Artery Aneurysm

Lateral Transcanthal-Microsurgical Resection of a Nontraumatic Intraorbital Ophthalmic Artery Aneurysm

A Ruptured Intraorbital Ophthalmic Artery Aneurysm, Associated with a Dural Arteriovenous Fistula: Combined Transarterial and Transvenous Endovascular Treatment

True aneurysms of the ophthalmic artery (OA) are extremely rare and most often arise at the origin of this artery. We present the endovascular management of a ruptured intraorbital OA aneurysm and of an associated dural arteriovenous fistula (dAVF). A patient with a ruptured intraorbital ophthalmic artery aneurysm, associated with a dAVF with cortical drainage presented with acute visual loss and intra- and periorbital hematoma. The aneurysm was treated by endovascular coil occlusion. The dAVF was occluded by transvenous obliteration of the draining basal vein of Rosenthal. Both intraorbital ophthalmic artery aneurysms and their rupture are extremely rare. Transvenous treatment of dAVFs is well feasible even with very far going catheterization, in this case to the origin of the basal vein of Rosenthal.

Clipping of a Cerebral Aneurysm in a Patient With Loeys-Dietz Syndrome: Case Report

his is the first case report of clipping a cerebral aneurysm in a patient with Loeys-Dietz syndrome (LDS). LDS is a newly described autosomal dominant connective tissue disease with systemic vascular involvement. Unique to this syndrome is the development of aneurysms at a young age with the propensity of dissection or rupture at a stage that is earlier than when surgical intervention is typically indicated. We describe the nuances in intraoperative and postoperative management. A 31-year-old woman who recently received a diagnosis of with LDS type II presented to neurosurgical attention for management of an unruptured right ophthalmic artery aneurysm. The patient underwent a right pterional craniotomy for clipping of the aneurysm, with lumbar drain placement before the procedure. Papaverine had to be used several times to counteract vasospasm of the vessels during arachnoid dissection. Because of vascular reactivity, temporary clipping was not used, and the aneurysm was clipped successfully. LDS is a newly described disorder that warrants awareness in the neurosurgical community because of its association with intracerebral aneurysms as well as craniosynostosis (19%), scoliosis (20%), cervical spine instability (7%), hydrocephalus, and Arnold-Chiari malformation. When clipping aneurysms in these patients, the surgeon should be aware of the potential for severe vascular reactivity during dissection and avoid temporary clipping when possible. Avoidance of lumbar drainage intraoperatively reduces the risk of intracranial hypotension after removal.

Endoscopic Endonasal Approach for Clipping of Ruptured and Unruptured Paraclinoid Cerebral Aneurysms: Case Report

We present a case in which clip ligation of both a ruptured and an unruptured paraclinoidal segment aneurysm is performed with only the endoscopic endonasal approach in 1 setting. A 42-year-old woman, a Hunt and Hess grade 2 patient, presented with aneurysmal subarachnoid hemorrhage. An arteriogram revealed an irregular 10-mm right paraclinoidal aneurysm projecting posteromedially and a 5-mm wide-necked right ophthalmic artery aneurysm projecting superomedially. The patient was taken to the operating room where clipping of both aneurysms was performed through the use of an endonasal endoscopic approach with a pedicled nasoseptal flap reconstruction. Such an approach allowed excellent visualization without drilling of the clinoid process or mobilization of the optic nerve and potential control of the proximal and distal internal carotid artery. An intraoperative arteriogram showed obliteration of both aneurysms with patency of the surrounding vasculature. The patient did well postoperatively and was subsequently discharged home without any neurological deficits. An endoscopic endonasal approach was immediately safe and effective for the clipping of both paraclinoidal aneurysms. Although there were benefits achieved from this particular unconventional approach, surgical clipping via traditional craniotomy and endovascular coiling are the established methods of aneurysm treatment and should always be primarily considered. More cases will determine the efficacy and safety of this approach, which should be attempted only by very experienced teams trained in both cerebrovascular and endonasal neurosurgery.

Embolization Using Endovascular Technique in Acute and Chronic Stages of Traumatic Ophthalmic Artery Aneurysm -Case Report-

A 44-year-old man presented with traumatic aneurysm of the left ophthalmic artery. The first coil embolization intervention achieved relatively tight packing of the aneurysm and the parent artery. After 5 months, a second embolization procedure was required because of recurrence of the aneurysm with transition of the intraaneurysmal coil formation. No recurrence occurred after the second embolization. We thought that the first embolization might have prevented catastrophic rupture, whereas the second embolization resulted in complete obliteration of the aneurysm. No entity of the aneurysmal wall formation of the current traumatic aneurysm in the acute stage may have resulted in the recanalization of the aneurysm followed by the second intervention. The stability of the wall in the chronic stage may correlate with the complete obliteration.

Peripheral ophthalmic artery aneurysm

Generally speaking, the term "ophthalmic aneurysms" refers to carotid-ophthalmic aneurysms, which arise from the internal carotid artery (ICA) wall at or around the origin of the ophthalmic artery (OA). In contrast, aneurysms arising from the OA stem or its branches, separate from the ICA are called peripheral OA aneurysms (POAAs). POAAs are a rare entity, which clinical features and natural course are not fully understood. A comprehensive literature review of reported aneurysms involving each segment of the OA was undertaken. The demographics, aetiology, clinical manifestations and treatment of reported POAAs are discussed. Of 35 retrieved cases, ten involved the intracranial segment, two were fusiform aneurysms in the optic canal, 17 arose from the intraorbital segment, and 6 involved either the lacrimal or the anterior ethmoidal branches. In 34 cases, clinical details were available; 18 patients experienced moderate to severe visual impairment including blindness, while seven patients had improvement in visual acuity as a result of surgical treatment. The present clinical review reveals that aneurysms of the OA stem and lacrimal branch are potentially threatening to visual acuity, while intracranial segment and anterior ethmoidal aneurysms can rupture and cause subarachnoid or intraparenchymal haemorrhage. Surgical intervention is mandatory in symptomatic cases to prevent visual deterioration or treat aneurismal rupture; alternatively, for small incidental POAAs "watchful waiting" may be indicated.

Infected giant ophthalmic artery aneurysm remnant following craniotomy for surgical clip ligation

Postoperative intracranial infections, although found in only a minority of surgical cases, remain a recognized potential complication following elective craniotomy. In the treatment of intracranial aneurysms, specifically, reports of significant postoperative infections are rare. Significant postoperative infections are usually observed in association with foreign bodies, such as aneurysm clips, endovascular coils, or materials used for aneurysm wrapping. The authors present a case in which a patient underwent craniotomy for surgical clip ligation of a giant ophthalmic artery aneurysm without resection of the aneurysm mass; the patient then presented again approximately 4 months later with a first-time seizure. Following a second craniotomy for resection of the aneurysm mass, the aneurysm contents were noted on pathological examination to contain gram-positive rods, and the aneurysm wall was noted to contain inflammatory cells. Although cultures were not obtained, Propionibacterium acnes was detected using polymerase chain reaction. To the best of the authors' knowledge, this case represents the second reported case of an intraaneurysmal abscess and the first reported instance of a presumed secondary infection of a giant intracranial aneurysm remnant following surgical clip ligation.

Ophthalmic segment aneurysmal subarachnoid hemorrhage presenting with contralateral abducens nerve palsy: A false localizing sign

Background Neuro-ophthalmic manifestations of aneurysmal subarachnoid hemorrhage are commonly linked to a palsy of the cranial nerve in close proximity to the aneurysm or to chronic intracranial hypertension. Case Report A patient with subarachnoid hemorrhage secondary to a rupture of an intracranial right ophthalmic segment internal carotid artery aneurysm presented with an acute-onset contralateral abducens nerve palsy. There were no clinical or radiologic features of chronic intracranial hypertension. Magnetic resonance imaging showed a co-existent ectatic basilar artery on the left side of the pons in close relation to the sixth nerve. Conclusion Abducens weakness in the above-50 age group is most commonly caused by a vascular etiology. The authors discuss the pathogenesis of this rare clinical entity and present pertinent literature review.

E-054 Endovascular rescue of a misshapen intracranial stent: report of two cases

BackgroundSince FDA approval in May 2007, closed cell intracranial stents have become increasingly used to assist aneurysm coil embolization. Inadvertent deformation and displacement of a deployed closed cell stent may...

P-013 Vessel deconstruction of the ophthalmic artery: potential diagnostic utility of balloon test occlusion study with electroretinography

PurposeVessel deconstruction of the ophthalmic artery is occasionally required in the treatment of periophthalmic internal carotid artery (ICA) intracranial aneurysms or more rare lesions such as dural arteriovenous fistulas (AVF),...

Optic nerve penetration by a carotico–ophthalmic artery aneurysm

Fenestration of a cranial nerve by an internal carotid artery aneurysm is rarely identified at surgical repair of intracranial aneurysms. Classically this condition is associated with visual disturbance in either acuity, fields or diplopia. We describe a patient with optic nerve fenestration by a carotico–ophthalmic artery aneurysm and discuss its likely pathophysiology. It is important to consider this anatomical variation during microsurgical approaches to the pericarotid and perioptic cisterns to prevent inadvertent damage to the optic apparatus.

011 The utilization of the Enzo steerable microcatheter for navigation of difficult anatomy in the treatment of a traumatic ophthalmic artery pseudoaneurysm

Introduction: The Enzo microcatheter (Micrus Endovascular Corp, San Jose, California, USA) is a deflectable microcatheter designed for intracranial applications. We report our experience using this aneurysm in a 45-year-old male...

009 Preservation of ophthalmic artery arising from aneurysm body during endovascular coil occlusion

Introduction and Purpose: Although several treatment strategies have been reported for preserving arteries arising from the dome of an aneurysm, current clinical practice suggests sacrifice of the parent artery is...

Alteration of intraaneurysmal hemodynamics by placement of a self-expandable stent

Development of a flexible self-expanding stent system and stent-assisted coiling technique facilitates endovascular treatment of wide-necked brain aneurysms. The hemodynamic effect of self-expandable stent placement across the neck of a brain aneurysm has not been well documented in patient-specific aneurysm models. Three patient-specific silicone aneurysm models based on clinical images were used in this study. Model 1 was constructed from a wide-necked internal carotid artery-ophthalmic artery aneurysm, and Models 2 and 3 were constructed from small wide-necked middle cerebral artery aneurysms. Neuroform stents were placed in the in vitro aneurysm models, and flow structures were compared before and after the stent placements. Flow velocity fields were acquired with particle imaging velocimetry. In Model 1, a clockwise, single-vortex flow pattern was observed in the aneurysm dome before stenting was performed. There were multiple vortices, and a very small fast flow stream was newly formed in the aneurysm dome after stenting. The mean intraaneurysmal flow velocity was reduced by approximately 23-40%. In Model 2, there was a clockwise vortex flow in the aneurysm dome and another small counterclockwise vortex in the tip of the aneurysm dome before stenting. The small vortex area disappeared after stenting, and the mean flow velocity in the aneurysm dome was reduced by 43-64%. In Model 3, a large, counterclockwise, single vortex was seen in the aneurysm dome before stenting. Multiple small vortices appeared in the aneurysm dome after stenting, and the mean flow velocity became slower by 22-51%. The flexible self-expandable stents significantly altered flow velocity and also flow structure in these aneurysms. Overall flow alterations by the stent appeared favorable for the long-term durability of aneurysm embolization. The possibility that the placement of a low-profile self-expandable stent might induce unfavorable flow patterns such as a fast flow stream in the aneurysm dome cannot be excluded.

Commentary

The pipeline embolization device (PED) is a flow-diverting stent that provides an additional treatment modality in the management of intracranial aneurysms. An aneurysm treated with a flow diverter is expected to involute over time, contrary to the immediate obliteration expected by surgical clipping or coiling. Yet, which aneurysms will respond to PED therapy and the time frame to expect full obliteration remain unclear.We report the unusual case of a 50-year-old woman with multiple (4 total) intracranial aneurysms who underwent multimodality treatment. Two aneurysms were treated with PEDs. Nine months later, the patient underwent a craniotomy for treatment of an additional aneurysm; at the time of surgery, one of the PED-treated aneurysms was noted to be clearly obliterated, and the other was visualized to be filling. The ophthalmic artery arose from the persistently filling aneurysm. The aneurysm was treated by clip ligation without incident.The rate of PED aneurysm obliteration increases with longer follow-up; however, the time frame for observing a persistently filling aneurysm before additional treatment is considered remains unknown. Some aneurysms may never close even after discontinuation of dual antiplatelet therapy. Ophthalmic artery aneurysms have been noted to fail treatment with PED based on the anatomic relationship of the aneurysm to the ophthalmic artery. This case provokes us to consider factors that may affect the latency to aneurysm obliteration, including aneurysm size, aneurysm morphology, patient gender, failure of previous aneurysm treatment, and duration of time from initial endovascular treatment.

Evaluation of Optic Strut Location and Orientation: An Anatomic Morphometric Study and a Proposed Classification Schema

Introduction: Understanding the anatomy of the optic strut with respect to its location, orientation, and dimensions is relevant to surgical approaches to ophthalmic artery aneurysms, anterior cavernous sinus lesions, and decompression of the optic canal.

Usefulness of a Simplified Management Scheme for Paraclinoid Aneurysms Based on a Modified Classification

Background: Our objective was to set up a management-oriented classification for paraclinoid aneurysms, and then design and apply a simplified management scheme according to each group defined by this classification. Methods: Paraclinoid aneurysms were classified as group I (supraophthalmic artery), group II (ophthalmic artery) and group III (infraophthalmic artery) aneurysms intradurally. Between January 2005 and December 2006, 86 cases with 89 paraclinoid aneurysms were treated. There were 35 (40.2%) aneurysms in group I (20 in group Ia, 15 in group Ib), 32 (36.8%) in group II and 20 (23%) in group III. Results: In group I aneurysms, 20 (57.1%) were treated by clipping or/and wrapping, while 15 (42.9%) were managed by coiling. In group II aneurysms, 20 (62.5%) were treated by clipping and 12 (37.5%) by coiling. The contralateral approach was performed for 4 (6%) aneurysms in groups I and II. All 20 group III aneurysms were treated by coiling. The overall rate of permanent complications was 4.6%. The rate of complete occlusion was 92.5% in surgical cases and 55.6% in endovascular ones. The overall outcomes in the treatment of paraclinoid aneurysms were excellent (GOS = 5, 95.4%). Conclusion: Based on our modified classification of paraclinoid aneurysms, a simplified management scheme was designed and applied. For group I (supraophthalmic artery) and group II (ophthalmic artery) aneurysms, surgical clipping or/and wrapping should be the first choice of treatment, while for group III (infraophthalmic artery) aneurysms, endovascular coiling should be the best modality. Additionally, individualizing the treatment planning might contribute to better results.

Eyelid approach to the anterior cranial base

Skull base approaches play a fundamental role in modern neurosurgery by reducing surgical morbidity. Increasing experience has allowed surgeons to perform minimally invasive approaches without straying from the premises of skull base surgery. The eyelid approach has evolved from the orbitopterional osteotomy into a more effective and targeted approach to disease of the anterior cranial fossa. In this technique, after an incision is made on the supratarsal fold, the orbicularis oculi muscle is incised, and a myocutaneous flap composed of the elements of the anterior lamella is elevated. Subperiosteal dissection is used to expose the superior and lateral walls of the orbit, the superior and lateral orbital rim, and the frontosphenoidal suture. A MacCarty bur hole is drilled, and a frontal osteotomy is fashioned medial to the supraorbital notch and extending through the orbital roof back toward the orbital half of the MacCarty bur hole, exposing the frontobasal brain. A conventional microsurgical technique is used to treat tumors and aneurysms of the anterior cranial fossa under the operative microscope. Five patients were treated for unruptured aneurysms of the anterior circulation (3 anterior communicating artery aneurysms, 1 ophthalmic artery aneurysm, and 1 posterior communicating artery aneurysm) using the eyelid approach. The mean aneurysm size was 5 mm, and all aneurysms were approached from the right side. Three tumors in the anterior fossa (2 suprasellar pituitary adenomas and 1 craniopharyngioma) were also excised using this approach. There was no surgical morbidity. Three months after surgery all patients presented excellent cosmetic results. The eyelid approach may be considered as an effective, cosmetically beneficial, and minimally invasive skull base approach to selected aneurysms and tumors of the anterior circulation.

Intracranial mycotic aneurysm: a case report

Intracranial mycotic aneurysms are extremely rare and commonly associated with infective endocarditis. The unusual location of these aneurysms should alert the clinician to the possibility of a mycotic aneurysm. We report an unusual case of a 46 year old woman with previous history of insulin dependent diabetes and an ophthalmic artery aneurysm clipped 10 years ago. She underwent a successful resection of a right frontoparietal meningioma, however, two weeks post‐operatively she presented with subarachnoid hemorrhage (SAH). An angiogram was performed and it was negative. She remained hospitalized and developed recurrent SAH two weeks later. A repeat angiogram revealed a distal basilar artery 1cm fusiform aneursym with irregular excrescences. She expired within 3 days of the last angiogram and a brain only autopsy was performed. The skull base showed extensive hemorrhage in the posterior fossa, SAH, right uncal and upward cerebellar herniation and a 2.5cm basilar tip aneurysm. Coronal sections of brain showed intraventricular hemorrhage with softening and necrosis of the brainstem. Histopathologic examination showed extensive acute and chronic inflammation with septae fungal hyphae present in the thrombi and the wall of the basilar tip aneurysm. A high index of clinical suspicion for mycotic aneurysm following surgical intervention may result in early treatment and improved patient outcome.